ORIGINALS PAPERS

 

Management of colonic volvulus. Experience in 75 patients

Manejo del vólvulo de colon. Experiencia en 75 pacientes

 

 

C. Mulas, M. Bruna, J. García-Armengol and J. V. Roig

Department of General Surgery and Digestive Diseases. Consorcio Hospital General Universitario de Valencia. Spain

Correspondence

 

 

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ABSTRACT

Background: the diagnostic and therapeutic management of colonic volvulus remains nowadays controversial. The election of the type of surgery, its timing, or the use of non-operative decompression must be based on the experience of a multidisciplinary team, the clinical condition of the patient, and the type of volvulus.
Objectives: the purpose of this study is to review our experience and results in the treatment of patients with colonic volvulus.
Material and methods: we performed a retrospective study of patients diagnosed of colonic volvulus between January 1990 and September 2008 in our institution.
Results: we included a total of 75 patients with a mean age of 72.7 years and, in most cases, with associated comorbidities and constipation. The most frequently involved segment was sigmoid colon (85.3%). A rectal tube insertion was used as the only therapeutic measure in 17 patients (22.4%), colonoscopic decompression in 17 (22.4%), and surgery in 41 patients (55.2%). Intestinal resection with primary anastomosis was the most common surgical option. Postoperative morbidity was 43%, being wound infections the most frequent complication. In the group of non-surgical treatment morbidity was 26.4%, albeit with a higher and early rate of recurrences.
Conclusions: treatment of colonic volvulus present important morbidity and mortality rates, and its treatment must be individualized. Resective surgery with primary anastomosis in clinically stable patients is the most appropriate therapeutic option, offering the lower recurrence rates.

Key words: Colonic volvulus. Intestinal obstruction. Endoscopic decompression. Surgical treatment.

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RESUMEN

Introducción: el manejo diagnóstico-terapéutico del vólvulo de colon continúa siendo un tema controvertido en la actualidad. En base a la situación clínica del paciente, a la experiencia de un equipo multidisciplinar, deben elegirse el tipo de cirugía, momento de su realización y el empleo de otras opciones descompresivas.
Objetivos: los objetivos del presente trabajo son revisar nuestra experiencia y resultados en el tratamiento de los pacientes con vólvulo de colon.
Material y métodos: hemos realizado un estudio retrospectivo descriptivo de los pacientes diagnosticados de vólvulo de colon entre enero de 1990 y septiembre de 2008 en nuestro centro.
Resultados: se han incluido un total de 75 pacientes, de edad media 72,7 años y, en su mayoría, con comorbilidades asociadas y estreñimiento. La zona de volvulación más frecuentemente implicada fue el sigma (85,3%). La sonda rectal fue utilizada como única medida terapéutica en 17 pacientes (22,4%), el tratamiento endoscópico en otros 17 (22,4%), y la cirugía en 41 (55,2%). La resección intestinal con anastomosis primaria fue la opción quirúrgica más empleada. La morbilidad postoperatoria fue del 43%, siendo las infecciones de herida la complicación más frecuente. En el grupo de tratamiento no quirúrgico la morbilidad fue del 26,4%, aunque con una mayor y más precoz tasa de recidivas.
Conclusiones: el vólvulo de colon presenta una elevada tasa de morbimortalidad asociada, debiendo realizarse su tratamiento de forma individualizada. La cirugía resectiva con anastomosis primaria en pacientes clínicamente estables es la opción terapéutica definitiva más adecuada y con menores tasas de recidiva.

Palabras clave: Vólvulo de colon. Oclusión intestinal. Descompresión endoscópica. Tratamiento quirúrgico.

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Introduction

Colonic volvulus is defined as the torsion of the large intestine around its mesenteric axis, which leads to an acute colonic obstruction. It represents in our medium between 5-10% of all cases of low intestinal obstruction (1).

Early and correct diagnosis of this entity, characteristic of the elderly, is essential to achieve an appropriate treatment aimed at correcting the electrolyte and nutritional changes that occur and restore the intestinal transit, solving the mechanical problem caused by the volvulus (2,3).

Currently, there is disagreement in the treatment of patients with colonic volvulus. On one hand, it seems evident that urgent resective surgery is the appropriate treatment for those who present an acute abdomen, intestinal perforation or ischemic necrosis of the intestinal mucosa (2-8). On the other hand, the initial management of patients clinically stable and in good general condition following endoscopic decompression is accepted in many institutions as a first therapeutic option. Controversy appears at the time of deciding the type of definitive treatment in each case as well as the strategy and most appropriate surgical technique (4,9).

There is little national bibliography and short series on this subject (10,11), so we have set as objectives of this study to review our experience and results in the treatment of patients with colonic volvulus.

 

Material and methods

We conducted a retrospective, descriptive study of patients diagnosed and treated for colonic volvulus in our center from January 1990 to September 2008 compiling a database.

Through detailed review of medical records of patients, epidemiological parameters have been recorded, as well as clinic presentation, physical examination and the different diagnostic-therapeutic methods employed in their management, including diagnostic imaging, ASA score, physiological Possum score, intraoperative findings and surgical technique or endoscopic procedure used in each case. We have also analyzed the clinical course of the episode, morbidity and mortality associated to each technique, its clinical effectiveness and recurrence rates.

Statistical analysis was performed using the SPSS* 15.0 version for Windows* (SPSS Inc., Chicago IL, USA) software package. We used chi-square test and Fisher exact test as appropriate for statistical comparison analysis. Mean and standard deviation were used as measures of central tendency and dispersion for sampling variables with a normal distribution. For those who do not follow a normal distribution, median and range were used. Significance was defined as p ≤ 0.05.

 

Results

A total of 75 patients with a mean age (SD) of 72.7 (16) years were included. Their clinical characteristics are described in table I.

Sigmoid volvulus was the most frequently involved segment, being present in 64 patients (85.3%). Much less common was cecal volvulus, present in 10 patients (13.3%), and transverse colon volvulus in only 1 patient.

Clinical presentation was variable although most of the patients presented intestinal obstructive symptoms, with a median (range) time evolution of 3 (0-30) days and a median (range) duration of constipation of 2 (0-10) days.

Among diagnostic tests, plain radiographs of the abdomen were obtained in 72 patients (96%), barium enema was used in 27 (36%), abdominal computed tomography in 8 patients and endoscopy in 43 (57.3%).

All patients were treated medically by nil per mouth, intravenous fluid therapy and analgesia. The procedures used specifically in the management of the colonic volvulus were: rectal tube placement, colonoscopic decompression and surgery. Figure 1 shows a diagram of the different procedures used and the evolution of our patients. Nine of the 41 patients treated surgically had a rectal tube placed before surgery and 7 underwent an endoscopy before surgery. All patients with cecal volvulus had surgery except one, in who, because of his bad general condition, was decided to try an endoscopic decompression, dying the patient of multiple organ failure.

Emergency surgery was performed in 20 out of the 41 patients (48.8%), deferred but during the same admission after decompression in 17 (41.4%), and programmed in a different admission of the volvulus episode in 4 cases (9.8%), with a median (range) of days from diagnosis to surgery of 4.5 (0-170). There were no significant differences regarding ASA and Possum scores between these groups of patients (Table II). Table III shows the comparative results in terms of morbidity and mortality between urgent and deferred surgery.

 

Resective surgery was the most common surgical option. We found significant differences between patients undergoing emergency surgery and deferred surgery (95.2 vs. 70%; p = 0.036). However, no significant differences were found when comparing the type of surgery performed (resection with primary anastomosis vs. Hartmann´s procedure). Endoscopic decompression allowed differing surgery and to improve patient´s general condition in 4 of the 7 cases where it was used prior to surgery.

Mechanical colonic cleansing was done before surgery in 15 patients (36.5%), but intraoperative colonic lavage was never used. During surgery, ischemic changes were found in 6 patients (7.9% of the total and 14.6% of those operated). This incidence was higher in patients who underwent emergent surgery (25 vs. 4.8%; p = 0.072).

There were complications in 18 of the 41 operated patients (43.9%), shown in table III. There was no statistically significant differences in morbidity of resected patients (14/34; 41.1%) versus unresected patients (4/7; 57.1%); p = 0.21. Hartmann´s procedure (intestinal resection and derivative colostomy) was associated with a postoperative morbidity of 50% (8/16), whereas in patients with primary anastomosis it was of 33.3% (6/18; p = 0.17). The mean duration of hospital stay (SD) was 16.2 (10) days, and during the follow-up a recurrence was presented in 2 patients (6.2%), 6 and 10 years after surgery.

A total of 34 (45.3%) patients were non-surgically treated, and complications occurred in 9 (26.4%) of them (Table IV). The co-morbidity associated to this group was higher than in the surgically treated group, showing almost 40% of these patients association of cardiorespiratory and systemic diseases compared to 9.5% in the surgical group, p = 0.016. The mean duration of hospital stay (SD) of this group was 8.1 (8) days. During follow-up, 13 (44.8%) recurrences were registered, being the difference statistically significant when compared with the surgical group (p = 0.005). The median (range) duration to first recurrence was of 3.5 (0-41) months in the conservative group versus 94.5 (77-112) months in the surgery group.

In the recent years, a bigger number of decompressive colonoscopies were conducted than in previous years (45% of cases in the period between 1990-1995 compared to 71.4% in 2003-2008). There seems to be a trend in recent years towards resection with primary anastomosis, although there were no statistically significant differences when compared (Table V).

 

Discussion

It was Rokitansky (3,12) who first defined in 1836 the colonic volvulus as an abnormal twisting of this intestinal portion on its mesenteric axis leading to an intestinal acute obstruction.

Sigmoid and cecal volvulus are the most common forms of these pathology, with a percentage of 60-70% and 20-30% of cases, respectively. Volvulus of the transverse and the splenic flexure of the colon represent less than 10% of intestinal volvulus (3,12).

Epidemiologically, colonic volvulus is more prevalent in geographical regions of Africa, Eastern Europe, Asia, and South America, where it represents up to 50% of all cases of intestinal obstruction (13), differing from Western Europe and the United States where the incidence is much lower, about 5-10% of all intestinal obstructions (1). In countries with a high prevalence of volvulus, they usually appear in middle-aged men, whereas in Western countries the average age is around 70 years (3,14), as in our series. Furthermore, physiological baseline status of these patients is usually quite poor, worsening when a bowel obstruction is present. The percentage of patients ASA III-IV in our series was over 70% with a mean p-Possum value close to 25.

Several factors have been associated with the appearance of colonic volvulus. The presence of a redundant and mobile sigmoid colon, with a narrow base of the mesenteric root, seems to be one of the major predisposing factors of this pathology. Similarly, an abnormal mobility of the cecal pole caused by an improper developmental fusion of the mesentery of the cecum and the ascending colon with the parietal peritoneum (7,15,16) that facilitates the torsion of the colon. There are described in literature some other predisposing factors, such as a high-fiber diet, constipation, previous abdominal surgery, old age, pregnancy, diabetes, or neurological and psychiatric diseases such as dementia or schizophrenia (3,5,14,17,18). Sigmoid volvulus has also been related to Hirschsprung´s disease (14,18) and megacolon from Chagas disease (14,18), finding sometimes a neoplasm to be the cause of the volvulus. In our series, the largest one recorded in Spain, over 80% of patients referred chronic constipation, and over one third suffered from neurological or psychiatric diseases, presenting almost a quarter of them a history of previous abdominal surgery.

Diagnosis is based on clinical, radiological and endoscopic findings, being occasionally done intraoperatively. The clinical picture of intestinal obstruction, with vomiting, bloating, abdominal pain and constipation, along with abdominal X-ray, are the basic pillars in the diagnosis of this pathology. Abdominal radiograph usually shows distended small-bowel loops with fluid levels. The presence of the "coffee bean" sign is highly suggestive of colonic volvulus, and it is present in about 30% of cases (12).

Other tests used in diagnosis include barium enema, computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic procedures, which can also be therapeutic achieving detorsion in many cases. The use of barium enema as a diagnostic and therapeutic method has been a controversial point, defending some authors that it only delays definitive surgical treatment of the volvulus (3,12,19).

The treatment of colonic volvulus remains still controversial, depending the election of the procedure and the most appropriate therapeutic approach on the clinical status of the patient, the location of the problem, the suspicion or presence of peritonitis, bowel viability and on the experience of the surgical team.

In the presence of peritonitis or intestinal gangrene, emergent resection of the affected segment is the most appropriate surgical option, performing a primary anastomosis if both the patient´s clinical condition and bowel ends are adequate. Resection with elaboration of a stoma (ileostomy or colostomy depending on the affected segment) is the recommended option in those cases of clinical instability of the patient, usually associated with severe peritonitis. Ören et al. (3), in a review of 827 cases of sigmoid volvulus, report a reduction in mortality when comparing cases of colonic volvulus that required urgent surgery and were treated by resection and primary anastomosis to cases operated under the same conditions who underwent a Hartmann´s procedure or proximal stoma. Many other authors (5,20) also support primary anastomosis in patients with intestinal gangrene but clinically stable.

In contrast, there are described in literature suture dehiscence rates close to 30%, and increased mortality rate in the group of patients with gangrene or peritonitis who underwent primary anastomosis after resection (2). In our experience we have found a minor dehiscence rate for this type of surgery compared to the results reported by different authors. However, no significant differences in morbidity and mortality were found when comparing to the resection without anastomosis nor when comparing resective versus non-resective surgery. So, as long as patient´s condition permits, we recommend performing resection and primary anastomosis in one time, decreasing this way the morbidity and mortality associated to two surgical procedures and the morbidity associated to the stoma.

Greater controversy exists in the management of colonic volvulus in the presence of a viable colon without clinical evidence of peritonitis. According to several studies, there seems to be general agreement in the use of decompressive colonoscopy as an initial treatment for colonic volvulus, with or without insertion of a rectal tube. Colonoscopy, besides being a therapeutic measure, it allows the evaluation of the colonic mucosa and therefore the presence or absence of signs of ischemia (21), being effective in more than 70% of patients (12,22). In case of failure of endoscopic decompression, which happens in most cases of volvulus of the cecum (23), surgery may be necessary.

If detorsion is effective, the current tendency is the indication of a deferred surgery in the coming days to detorsion, given the high rates or recurrence of the volvulus if only nonsurgical measures are applied. Several studies have shown recurrence rates up to 90% following a successful nonsurgical detorsion. Grossman et al. (9) observed a mortality rate of 6% for elective surgery after decompressive colonoscopy in sigmoid volvulus. In contrast, for those cases treated only by colonoscopic detorsion they observed a mortality rate of 12%, recurrence rate of 23% and a mortality rate associated to the recurrence episode of 20%, so they recommend surgery as a definitive treatment for colonic volvulus. In our series, we have recorded a high rate of recurrences after conservative treatment which occurs more precociously that recurrences recorded after surgical treatment.

Cecopexy and cecostomy are part of the non-resective surgical options in the treatment of colonic volvulus, but when compared to previously exposed resective treatment, worst results in terms of mortality, which represents up to 40% (7), were found. This is probably due to the fact that they are used in patients with high surgical risk. However, these two procedures prevent recurrences in some cases and could be options to have in mind in high risk and clinically unstable patients.

Currently, laparoscopic approach is a valid option in the treatment of this pathology, with good results according to different published series (24,25), improving hospital stay, postoperative pain and the morbidity associated to this surgery, specially abdominal wall problems.

In conclusion, colonic volvulus are, in our country, a disease of elderly people with considerable comorbidity, so its diagnostic and therapeutic management must be performed by a multidisciplinary and specialized team, being the resection with primary anastomosis a safe method in patients with appropriate clinical conditions and after a successful endoscopic decompression with no signs of intestinal ischemia or peritonitis.

 

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Correspondence:
Claudia Mulas Fernández.
Servicio de Cirugía General y del Aparato Digestivo.
Consorcio Hospital General Universitario de Valencia.
Avda. Tres Cruces, s/n. 46014 Valencia.
e-mail: claudiamulas@comv.es

Received: 27-08-09.
Accepted: 17-12-09.